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Yasawardene P, Jayarajah U, De Zoysa I, Seneviratne SL. Nephrotoxicity and neurotoxicity following star fruit (Averrhoa carambola) ingestion: a narrative review. Trans R Soc Trop Med Hyg 2021; 115:947-955. [PMID: 33693950 DOI: 10.1093/trstmh/trab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 01/06/2023] Open
Abstract
In recent times, star fruit (Averrhoa carambola) nephrotoxicity and neurotoxicity have been increasingly reported, both in individuals with pre-existing renal disease and those with previously normal renal function. We summarise the clinical findings of star fruit toxicity in humans and outline the important pathogenetic insights provided by animal studies. Google Scholar, EMBASE, Scopus and PubMed were searched from 1995 through July 2020 for case reports/series on renal or neurological manifestations of star fruit toxicity in humans and mechanisms of star fruit toxicity in animal studies. Ten case series and 28 case reports in humans (total number of individuals=136) were included and 8 animal studies were analysed. Ninety-four (69.1%) patients had prior renal impairment. Renal histology showed acute oxalate nephropathy with tubulointerstitial nephritis or tubular necrosis. Neurotoxicity manifestations ranged from hiccups to status epilepticus. Oxalate and caramboxin are considered the main substances causing nephrotoxicity and neurotoxicity. Caramboxin inhibits GABA binding and activates the glutamatergic receptors. Haemodialysis improved outcomes in neurotoxicity. Nephrotoxicity and neurotoxicity need to be looked for with star fruit toxicity, both in individuals with abnormal or normal renal function. Once star fruit intoxication is identified, early renal replacement therapy should be considered. Further studies on the mechanisms of star fruit toxicity are needed.
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Affiliation(s)
- Pamodh Yasawardene
- Faculty of Medicine, University of Colombo, P.O. Box 271, Kynsey Road, Colombo 08, Sri Lanka
| | - Umesh Jayarajah
- Postgraduate Institute of Medicine, University of Colombo, 160, Prof. Nandadasa Kodagoda Mawatha, Colombo 07, Sri Lanka
| | - Ishan De Zoysa
- Department of Surgery, Faculty of Medicine, University of Colombo, P.O. Box 271, Kynsey Road, Colombo 08, Sri Lanka
| | - Suranjith L Seneviratne
- Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo 02, Sri Lanka
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Vazquez-Revuelta P, Andrés-López B, Bartolomé B, Corominas M, Lleonart R. Anaphylactic shock after first exposure to star fruit in a bird keeper. Ann Allergy Asthma Immunol 2021; 126:437-438. [PMID: 33450399 DOI: 10.1016/j.anai.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/15/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Paula Vazquez-Revuelta
- Allergology, Department of Internal Medicine, Hospital Universitari Bellvitge - Institut d'Investigació Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Blanca Andrés-López
- Allergology, Department of Internal Medicine, Hospital Universitari Bellvitge - Institut d'Investigació Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Mercè Corominas
- Allergology, Department of Internal Medicine, Hospital Universitari Bellvitge - Institut d'Investigació Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ramon Lleonart
- Allergology, Department of Internal Medicine, Hospital Universitari Bellvitge - Institut d'Investigació Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Mechanisms of star fruit (Averrhoa carambola) toxicity: A mini-review. Toxicon 2020; 187:198-202. [PMID: 32966829 DOI: 10.1016/j.toxicon.2020.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 12/17/2022]
Abstract
The star fruit (Averrhoa carambola) is consumed in high amounts in Asia and Central/South America. It contains oxalic acid and caramboxin. In some individuals, its ingestion may lead to nephrotoxicity and neurotoxicity. The nephrotoxic effect is due to oxalate deposition in renal tubules resulting in acute tubular necrosis and interstitial nephritis. Although uraemic encephalopathy secondary to acute kidney injury may play a role, a shift to an excitatory state of the central nervous system (CNS) by caramboxin through activation of excitatory neuroreceptors and inhibition of GABA receptors leads to mental confusion, seizures and status epilepticus seen with star fruit intoxication. In this mini-review, we discuss the mechanisms of star fruit-related toxicity.
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Resiere D, Kallel H, Oxybel O, Chabartier C, Florentin J, Brouste Y, Gueye P, Megarbane B, Mehdaoui H. Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes. TOXICS 2020; 8:toxics8020028. [PMID: 32283693 PMCID: PMC7356022 DOI: 10.3390/toxics8020028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/27/2022]
Abstract
The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients. METHODS A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité. RESULTS During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients. CONCLUSIONS Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.
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Affiliation(s)
- Dabor Resiere
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
- Correspondence: ; Tel.: +1-(596)-6-9620-3184
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital; 97300 Cayenne, French Guiana,
| | - Odile Oxybel
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Cyrille Chabartier
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Jonathan Florentin
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Yannick Brouste
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Papa Gueye
- Emergency Medical Services (Service d’aide médicale d’urgence 972), 97261 Martinique, France;
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMR-S 1144, 75013 Paris, France;
| | - Hossein Mehdaoui
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
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Wijayaratne DR, Bavanthan V, de Silva MVC, Nazar ALM, Wijewickrama ES. Star fruit nephrotoxicity: a case series and literature review. BMC Nephrol 2018; 19:288. [PMID: 30348106 PMCID: PMC6198447 DOI: 10.1186/s12882-018-1084-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 10/08/2018] [Indexed: 01/30/2023] Open
Abstract
Background Star fruit is a popular medicinal fruit in the tropics. Its hypoglycaemic properties are considered useful in achieving glycaemic control in diabetes. Star fruit induced nephrotoxicity is a rare cause of acute kidney injury in individuals with both normal and reduced baseline renal function. We present three cases of acute kidney injury due to star fruit nephrotoxicity from Sri Lanka, and discuss the published literature on this topic. Case presentation Three Sri Lankan patients, all with a background of diabetes, presented to us with acute nausea and anorexia following recent consumption of star fruit. Two patients complained of diarrhoea and one patient complained of intractable hiccoughs. They all had elevated serum creatinine on admission. Two were known to have normal baseline serum creatinine levels. On renal biopsy two had evidence of oxalate crystal deposition. One did not show crystal deposition but had acute interstitial nephritis for which no alternate cause could be identified. Two were treated with short courses of prednisolone and two required acute haemodialysis. All recovered renal function, with both patients with known baselines approaching their premorbid serum creatinine levels. Conclusion Consumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged.
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Affiliation(s)
| | - V Bavanthan
- Nephrology, Dialysis and Transplant Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - M V C de Silva
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - A L M Nazar
- Nephrology, Dialysis and Transplant Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Eranga S Wijewickrama
- Univeristy Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka.,Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Chua CB, Sun CK, Tsui HW, Yang PJ, Lee KH, Hsu CW, Tsai IT. Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication. Clin Toxicol (Phila) 2017; 55:624-628. [PMID: 28443386 DOI: 10.1080/15563650.2017.1314490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Star fruit (SF) is a commonly available fruit produced and eaten in tropical and subtropical countries. Since 1993, various reports have described neurotoxicity after eating SF, but this clinical condition remains unfamiliar. We aimed to describe this clinical entity, the role of renal dysfunction in this disorder, treatment strategies, and prognosis of patients with SF intoxication. METHODS We conducted a search of PubMed and Google Scholar databases from 1993 to 2016. We included reports describing patients with a clear history of SF ingestion with acute symptoms. We described the demographic characteristics, reported SF intake, treatments used, and outcomes. RESULTS We reviewed totally 126 patients (male:female = 1.5:1) from 33 articles with mean age 54.4 ± 11 (range: 30-84). The most common symptom was hiccups (65%), whereas confusion and seizure were the most common symptoms associated with mortality (42% and 61%, respectively). Pre-intoxication renal function also affected mortality. While there was no mortality in patients with normal renal function (NRF), the mortality of patients among reported cases with chronic renal insufficiency and end-stage renal disease undergoing dialysis were 36% and 27%, respectively. With the inclusion of patients reported to have NRF, the overall mortality was 24%. Consistently, the number of SF consumed was substantially higher in the patients with NRF than those with renal functional impairment. The most common treatment strategy was hemodialysis (59%). CONCLUSIONS Patients with impaired renal function were at higher risks of SF intoxication. Severe neurologic symptoms mandate immediate medical intervention because of the association between their occurrence and high mortalities. Toxin removal through dialysis, rather than symptomatic relief, seems to be beneficial to patient survival. Early and continuous dialysis appears to alleviate severe symptoms and prevent symptom rebounds.
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Affiliation(s)
- Choon-Bing Chua
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Cheuk-Kwan Sun
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Huan-Wen Tsui
- b Department of Neurology , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Po-Jen Yang
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Kuo-Hsin Lee
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Chih-Wei Hsu
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - I-Ting Tsai
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
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Star fruit toxicity: a cause of both acute kidney injury and chronic kidney disease: a report of two cases. BMC Res Notes 2015; 8:796. [PMID: 26680759 PMCID: PMC4683968 DOI: 10.1186/s13104-015-1640-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 10/27/2015] [Indexed: 11/10/2022] Open
Abstract
Background Star fruit (Averrhoa carambola) is commonly consumed as a herbal remedy for various ailments in tropical countries. However, the dangers associated with consumption of star fruit are not commonly known. Although star fruit induced oxalate nephrotoxicity in those with existing renal impairment is well documented, reports on its effect on those with normal renal function are infrequent. We report two unique clinical presentation patterns of star fruit nephrotoxicity following consumption of the fruit as a remedy for diabetes mellitus—the first, in a patient with normal renal function and the second case which we believe is the first reported case of chronic kidney disease (CKD) due to prolonged and excessive consumption of star fruits. Case presentation The first patient is a 56-year-old female diabetic patient who had normal renal function prior to developing acute kidney injury (AKI) after consuming large amount of star fruit juice at once. The second patient, a 60-year-old male, also diabetic presented with acute on chronic renal failure following ingestion of a significant number of star fruits in a short duration with a background history of regular star fruit consumption over the past 2–3 years. Both had histologically confirmed oxalate induced renal injury. The former had histological features of acute tubulo-interstitial disease whilst the latter had acute-on-chronic interstitial disease; neither had histological evidence of diabetic nephropathy. Both recovered over 2 weeks without the need for haemodialysis. Conclusion These cases illustrate the importance of obtaining the patient’s detailed history with respect to ingestion of herbs, traditional medication and health foods such as star fruits especially in AKI or CKD of unknown cause. Electronic supplementary material The online version of this article (doi:10.1186/s13104-015-1640-8) contains supplementary material, which is available to authorized users.
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Yung I, Leung H, Ng J, Ma T, Chow KM, Mok V, Wong L. An exotic cause of encephalopathy in a patient with chronic kidney disease. Neurol Clin Pract 2014; 4:490-492. [PMID: 29443145 PMCID: PMC5759986 DOI: 10.1212/cpj.0000000000000007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Iris Yung
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Howan Leung
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Jack Ng
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Terry Ma
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Kai Ming Chow
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Vincent Mok
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - Lawrence Wong
- Divisions of Neurology (IY, HL, VM, LW) and Nephrology (JN, TM, KMC), Department of Medicine and Therapeutics, The Chinese University of Hong Kong
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Intoxications. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0610-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wu CL, Chiu PF, Yang Y, Wen YK, Chiu CC, Chang CC. Sustained low-efficiency daily diafiltration with hemoperfusion as a therapy for severe star fruit intoxication: a report of two cases. Ren Fail 2011; 33:837-41. [PMID: 21770853 DOI: 10.3109/0886022x.2011.599048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Over the past decade, star fruit (Averrhoa carambola) intoxication decreased in the Taiwanese society due to improved public education on chronic kidney disease (CKD). Various complications including hiccups, altered levels of consciousness, coma, and seizures have been reported in individuals with renal failure who ingested fresh star fruit or star fruit juice. A high mortality rate (from 33 to 80%) was observed in patients with altered levels of consciousness, despite prompt dialysis and supportive care. According to previous case reports, the proposed treatment of choice for severe star fruit intoxication may be continuous renal replacement therapy with or without hemoperfusion. We report two cases of star fruit intoxication with stage V CKD (one case is predialysis) presenting with coma and generalized tonic-clonic seizures. The two patients were treated with sustained low-efficiency daily diafiltration (SLEDD-f) and charcoal hemoperfusion. Status epilepticus was controlled fairly quickly after treatment with SLEDD-f and hemoperfusion. However, the outcomes in this report are still poor (both remained comatose; one of two patients died). Currently, there are no data for the use of SLEDD-f with hemoperfusion for severe star fruit intoxication. SLEDD-f with charcoal hemoperfusion may play a role in managing refractory status epilepticus in patients with severe star fruit poisoning.
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Affiliation(s)
- Chia-Lin Wu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 2010; 36:196-209. [PMID: 20057995 PMCID: PMC2816797 DOI: 10.1007/s00134-009-1742-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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Auxiliadora-Martins M, Alkmin Teixeira GC, da Silva GS, Viana JM, Nicolini EA, Martins-Filho OA, Basile-Filho A. Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit. Heart Lung 2009; 39:448-52. [PMID: 20561840 DOI: 10.1016/j.hrtlng.2009.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/03/2009] [Accepted: 09/09/2009] [Indexed: 12/11/2022]
Abstract
Star fruit (Averrhoa carambola) is a popular tropical fruit that is usually consumed as fresh fruit or fruit juice. Consumption of star fruit by patients with chronic renal failure can lead to neurologic symptoms. The present report describes the clinical course, management, and outcome of a patient with chronic renal failure admitted to an intensive care unit after ingestion of star fruit juice 2 days before hospital admission. A case of nausea, vomiting, intractable hiccups, and severe encephalopathy along with mental confusion, disorientation, agitation, and seizures in a 53-year-old woman is presented. The patient's ventilatory pattern worsened, with development of dyspnea and tachypnea, which resulted in her transfer to an intensive care unit. Although hemodialysis was performed and the septic shock was adequately treated, the patient died on the fifth day after hospital admission. The susceptibility of patients with chronic renal failure to star fruit and the severity of intoxication are poorly known by intensivists. This case demonstrates that star fruit consumption should be considered as a cause of rapid deterioration in the renal function of patients with underlying chronic renal failure, potentially resulting in a fatal outcome.
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Affiliation(s)
- Maria Auxiliadora-Martins
- Centro de Terapia Intensiva (Campus), Departamento de Cirurgia e Anatomia, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo-HCFMRP-USP, Bairro Monte Alegre, Ribeirão Preto, SP, Brasil
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